[Reducing the risk of vascular complications during percutaneous aortic valve replacement]

The percutaneous aortic valve replacement (TAVI) is the most recent and promising procedure in the area of interventional cardiology with a rapidly growing number of interventions worldwide. The transfemoral approach being less invasive, it has become the predominant access for the device delivery. The prevention of vascular complications by an optimal risk stratification using appropriate imaging techniques (vascular CT scan and angiography), optimised techniques for femoral puncture (active control of the arterial punction, crossover...) and skilled teams for peripheral angioplasty and percutaneous arterial closure devices (Prostar) has become mandatory given the fragile target population for TAVI. Vascular complications remain indeed one of the most frequent complication although the trend toward reduced sheeths size led to significant reduction This is mandatory regarding the needed size of the vascular arterial access - itself with constant improvement by minimising the initial 24 French with mandatory real chirurgical closure to the actual 18-19 French and soon 16 French. The improvement of the implanted devices is due to the recent evidence of the promising future of this technique and the important technological effort realised by the industry not only on the implanted aortic prosthesis but also on their delivering catheters.

Agropine in "null-type" crown gall tumors: Evidence for generality of the opine concept

Agrobacterium Ti (tumor-inducing) plasmids, the causative agents of crown gall disease, fall into four genetic groups based on the patterns of octopine and nopaline synthesis (by crown gall tumors) and catabolism (by Agrobacterium tumefaciens) for which they are responsible. Two classes of Ti plasmids induce tumors that synthesize neither octopine nor nopaline. The existence of these Ti plasmids challenged the view that opines such as octopine and nopaline play a central role in crown gall biology. We now report the occurrence of an opine in tumors induced by one of these classes of Ti plasmids, the "null-type" plasmids typified by pTi Bo542. The opine was purified by biological enrichment based on its utilization by bacteria containing pTi Bo542 but not by bacteria lacking a Ti plasmid. The mass spectrum and biological properties of this opine are identical to those of agropine, an opine recently discovered in octopine-type tumors. We propose that null-type Ti plasmids now be named for their signal opine, agropine-type Ti plasmids.

[Pertinence of the 2000 WHO criteria in non-immune children with severe malaria in Dakar, Senegal ]

The relevance of World Health Organization (WHO) criteria for severe malaria has not been assessed in non-immune children. The objectives of this study were (i) to evaluate the significance of 1990 WHO definition reconsidered in 2000 on distribution and lethality of severe cases in children admitted with falciparum malaria, and (ii) to contribute to the study of relevance of the WHO severe criteria in Dakar, an hypoendemic area in Senegal.

PATIENTS AND METHODS

The 1990 WHO criteria, respiratory distress and platelet counts were prospectively collected in 1997-99 from children admitted to Hôpital Principal de Dakar, Senegal, with falciparum malaria diagnosed on a thick blood film. This method allowed also the definition of severe cases according to 2000 WHO criteria.

RESULTS

Among 311 patients (median age: 8 years old), according to the 2000 WHO criteria, the frequency of severe malaria cases was increased by 23% (75% versus 52%) and case-fatality rates thereof were decreased by 5% (17% versus 12%) compared with 1990 WHO definition. One death occurred among cases defined as severe on admission only according to criteria modified by WHO in 2000. A multivariate logistic regression model identified several independent prognostic factors: cerebral malaria, hypoglycaemia, respiratory distress, renal failure, collapse, abnormal bleedings, pupillary abnormalities and thrombocytopaenia defined as a platelet count below 100,000/mm3. A significant association (p < 0.001) was observed between platelet count increase and consciousness level improvement, evaluated on day of first platelet count control (time from admission: 1-7 d). Among survivors, a lesser improvement in coma score was associated with a decrease in platelet counts (p < 0.04).

CONCLUSIONS

The 1990 WHO criteria, which predicted death among malaria cases in children living under stable falciparum transmission, are relevant in this series of non-immune children living in a low and seasonal transmission. Nevertheless new WHO criteria showed poor prognostic significance. However, the 2000 WHO definition was highly sensitive to detect severe malaria cases. These findings should be considered for managing severe malaria in migrant children.

Thrombocytopenia and Plasmodium falciparum malaria in children with different exposures

We studied thrombocytopenia during acute Plasmodium falciparum malaria in 64 traveller children from Paris (France), 85 children from Dakar (Senegal) with an intermittent exposure (69 with severe attack or cerebral malaria), and 81 children from Libreville (Gabon) with a perennial exposure (43 with severe attack or cerebral malaria). Initial thrombocytopenia was present in 43-58% of children with P falciparum malaria but was not more frequent in severe outcome or cerebral malaria. Low parasitaemia may lead to the misdiagnosis of malaria and delayed treatment when there is associated thrombocytopenia

[Epidemiology and prognosis of childhood injuries in Dakar, Senegal]

The impact of accidental injury on childhood morbidity and mortality in Africa is underestimated. The frequency and severity of accidents is high. This retrospective study includes 381 children (3% of admission) between the ages of 0 and 15 years hospitalized for accidental injury at the Principal Hospital in Dakar, Senegal, between January 1, 1997 and December 31, 2000. The annual incidence of childhood injury doubled over the 4-year study period. Mean age was 48 months and the M/F sex ratio was 1.7. The causes were trauma (n = 184) due to domestic accidents (n = 109 including 91 falls) or road accidents (n = 75), poisoning (n = 129 including 38 caustic soda burns), foreign body aspiration or ingestion (n = 30), burns (n = 18), and miscellaneous accidents (n = 20). Most fatalities (9%) were due to road accidents and falls. Rapid uncontrolled urbanization and problems of displaced rural populations in adapting to city living may account for the high frequency of falls from high buildings and road accidents. As in industrialized countries road accidents, though not the most frequent, are the most lethal. Lack of emergency services accounts for severity. Vigorous information campaigns and prevention action will be needed to lower the high morbidity and mortality of childhood injury in developing countries.

[Epidemiology and prognosis of childhood cancers in Dakar, Senegal]

Childhood cancer has often been considered as a problem mainly affecting industrialized countries. In reality more than half of cases occur in developing countries where management and diagnosis are major issues. This retrospective study includes 130 children (0.3% of admissions) between the ages of 0 and 15 years hospitalized for malignant disease at the Principal Hospital in Dakar, Senegal between January 1, 1990 and December 31, 2000. Mean age was 97 months and M/F sex ratio was 1.2. Mean delay for admission was 3 months. The five most frequent cancers, accounting for 75% of cases, were leukemia (n = 28), lymphoma (n = 21), nephroblastoma (n = 21), retinoblastoma (n = 16) and osteochondrosarcoma (n = 10). Treatment was completed in 18% of cases. Half of patient were lost from follow-up. The cure rate was 10% overall and 50% for patients receiving complete treatment. The highest cure rate was achieved for nephroblastoma, i.e., 58% of cases treated. Management of childhood cancer in Africa is confronted with numerous problems, namely, paucity of specialized staff, absence of expert centers, shortage of anticancer drugs, lack of financial resources, and delay in treatment. These factors associated with frequent malnutrition and recurrent infectious diseases, greatly lower cure rates in comparison with industrialized countries.

[Particularities of the immune response in neurocysticercosis]

Unique physiological and immunological features of the brain, as previously presented, explain the limitation of local inflammatory reactions and the existence of intrathecal specific IgG production. In addition, some parasitic factors of recent knowledge are induced during neurocysticercosis, which could be involved in vivo in a modulation of the immune response by larval products (a soluble RNA-peptide, some metacestode surface sphingoglycolipids). These recent findings lead us to make a critical review of the antigenic profiles obtained by enzyme-linked immunoelectrotransfer blot (EITB) on samples collected from patients suffering from simple or multiple neurocysticercosis.

Severe falciparum malaria in children: a comparative study of 1990 and 2000 WHO criteria for clinical presentation, prognosis and intensive care in Dakar, Senegal

The relevance of WHO criteria for severe and complicated malaria has been debated for a while, especially as regards children. Recent data led WHO experts to modify the definition of severe malaria. The objective of this study was to evaluate retrospectively the significance of the new definition on severity, lethality and intensive care distribution in children admitted with falciparum malaria (in 1997-99) to Hôpital Principal de Dakar, Senegal. We used the paediatric risk of mortality score (PRISM) to compare the 2 definitions, WHO 2000 and WHO 1990. Finally, we evaluated the impact of the new definition in terms of major therapeutic interventions (MTIs): mechanical ventilation, haemodynamic support, transfusion, haemodialysis, and the use of sedatives. Among 311 patients, the frequencies of severe malaria cases and case-fatality rates thereof were 52% (n = 161) and 17% (n = 28) respectively using the 1990 WHO criteria, and 75% (n = 233) and 12% (n = 28) using the 2000 WHO criteria. Mean PRISM score among severe cases decreased with the new definition (6.5 versus 8.6). Both definitions predicted neurological sequelae and deaths with 100% sensitivity. One or more MTIs were required in severe malaria cases in 86% (n = 139) under the 1990 criteria and 73% (n = 170) under the 2000 criteria. In this area of low and seasonal transmission, the 2000 WHO definition of severe malaria proved broader and less specific, but was easier to apply and retained the high sensitivity of the earlier definition in identifying life-threatening infections.

Stent placement compared with balloon angioplasty for small coronary arteries: in-hospital and 6-month clinical and angiographic results

BACKGROUND

Stenting has been demonstrated to be superior to balloon angioplasty in de novo focal lesions located in large native vessels. However, in small vessels, the benefit of stenting remains questionable.

METHODS AND RESULTS

A total of 381 symptomatic patients with de novo focal lesion located on a small coronary segment vessel (<3 mm) were randomly assigned to either stent implantation (192 patients; 197 lesions) or standard balloon angioplasty (189 patients; 198 lesions). The primary end point was the angiographic restenosis rate at 6 months, as determined by quantitative coronary angiography. On intention-to-treat analysis, angiographic success rate and major adverse cardiac events were comparable: 97.9% and 4.6% versus 93.9% and 5.8% in the stent group and the balloon group, respectively. After the procedure, a larger acute gain was achieved with stent placement (1.35+/-0.45 versus 0.94+/-0.47 mm, P=0.0001), resulting in a larger minimal lumen diameter (2.06+/-0.42 versus 1.70+/-0.46 mm, P=0.0001). At follow-up (obtained in 91% of patients), angiographic restenosis rate was 21% in the stent group versus 47% in the balloon group (P=0.0001), a risk reduction of 55%. Repeat target lesion revascularization was less frequent in the stent group (13% versus 25%, P=0.0006).

CONCLUSIONS

Elective stent placement in small coronary arteries with focal de novo lesions is safe and associated with a marked reduction in restenosis rate and subsequent target lesion revascularization rate at 6 months.

Characterization of novel di- and tricarboxylic acids in fine tropical aerosols

Three unknown di- and tricarboxylic acids were characterized in the fine size fraction of aerosols which were collected during the wet season in the Amazon basin (Rondonia, Brazil). For the structural characterization of the methyl esters of these unknown compounds, mass spectrometry with electron ionization (EI) and tandem mass spectral techniques combined with gas chromatographic (GC) separation were employed. Fragment and parent ion spectra were recorded during elution of the GC peaks by linked scanning of the B and E sectors in combination with high-energy collision-induced dissociation. The fragmentation patterns of significant ions in the first-order EI spectra were also obtained for nonanedioic acid, which was examined as a model compound. The compounds were tentatively identified as 4-acetyloxyheptanedioic acid and cis and trans isomers of 5-hexene-1,1,6-tricarboxylic acid. Since there were indications of biomass burning during the aerosol sampling the di- and tricarboxylic acids characterized in the present work could be markers for biomass burning. Furthermore, the characterization of di- and tricarboxylic acids in the fine size fraction of atmospheric aerosols may be important for assessing the effects of organic aerosols in cloud formation.

[Renocutaneous fistula: report of a chronic inguinal fistula]

The authors report a new case of isolated spontaneous nephrocutaneous fistula revealed by a persisting draining sinus in the left groin. Their present causative factors are identified. The computed tomography and magnetic resonance imaging actually may resolve the diagnostic dilemma and are helpful in the surgical treatment.

Assessment of left ventricular regional wall motion by color kinesis technique: comparison with angiographic findings

The analysis of segmental wall motion using two-dimensional (2-D) echocardiography is subjective with high interobserver variability. Color kinesis is a new technique providing a color-encoded map of endocardial motion. We evaluated the accuracy of color kinesis and 2-D for assessment of regional asynergy compared with left ventricular angiography as a reference method. Fifteen patients admitted for myocardial infarction were studied by echocardiography the day before left ventricular angiography. The left ventricle was divided into seven segments. Each segment was classified by two independent observers as normal or abnormal in 2-D and color kinesis. Accuracy of color kinesis and 2-D was evaluated and compared to left ventricular angiography. Color kinesis is significantly superior to 2-D for all seven segments (mean 0.80/0.68, P = 0.05), except for the septum (0.67/0.60, P = NS). Interobserver variability studied by chi-square statistic is lower with color kinesis (0.70) than with 2-D (0.57). We conclude that these data suggest that color kinesis is a useful method for assessing systolic wall motion in all segments, except the septum and for improving the accuracy of segmental ventricular function and interobserver variability.

[Pre-hospitalization treatment with Abciximab in the preparation of patients for primary angioplasty in the acute phase of myocardial infarct. Immediate and long-term (one month) results]

Percutaneous transluminal coronary angioplasty (PTCA) is an alternative to fibrinolysis in the treatment of acute myocardial infarction (AMI). However, after balloon PTCA, the rate of early re-occlusion, of re-infarctus and of restenosis remains high. Stent implantation with antiplatelet drug regimen (aspirin, ticlid) limits these risks. Abciximab (new GPIIb/IIIa receptors inhibitor) reduces PTCA complications rate in the acute coronary syndromes. Intravenous administration of abciximab can restore a normal flow in the infarcted related coronary artery (IRA) after few minutes. A monocentric, non randomized, prospective pilot study was iniated to assess the feasibility of pre-hospital treatment with abciximab in preparation to primary PTCA stenting in AMI (primary endpoint) and to appreciate potential benefits in initial IRA patency as well as prevention of PTCA thrombotic complications (secondary endpoint). Between April 1997 and January 1998, 38 AMI were treated with abciximab in pre-hospital phase (group A). Mobil Intensive Care Unit (MICU) team implemented the treatment and guaranteed immediate transport to the cathlab (abciximab bolus-coronary angiography time = 37 +/- 17 min). Immediate results were compared to those of 198 paired patients who were treated for AMI during the same period (Group T). Initial IRA flow TIMI grade 3 was significantly higher in group A, 24%, than in group T, 9% (p < 0.017). The rates of per-procedural complications (no flow, distal embolism), of local complications, of transfusions were not significantly different. During 1 month follow-up, there was no significant difference between group A and group T concerning death, re-MI, stent thrombosis and new revascularization. To conclude, the pre-hospital treatment with abciximab in AMI is feasible by MICU medical team without any delay of the cathlab admission. It is associated with no increased hemorrhagic complications rate. The abciximab pre-hospital treatment improves the initial IRA patency. These encouraging preliminary results expect to be confirmed by larger, multicentric, randomized and prospective studies.

[Congenital tuberculosis: difficulties in early diagnosis]

BACKGROUND

Neonatal and/or congenital tuberculosis is insufficiently understood.

CASE REPORTS

Case 1. A premature hypotrophic neonate presented at the age of 45 days, without any maternal contact, a bilateral bronchopneumopathy. Whilst the pregnancy and birth had not been affected by any noteworthy problem, the mother died from miliary tuberculosis despite rifampin, isoniazid and pyrazinamide treatment. Her baby also died on day 52 from multivisceral failure. Culture of tracheal secretions confirmed a few weeks later the diagnosis of tuberculosis. Case 2. A premature, hypotrophic neonate presented on day 22 signs of respiratory distress (miliary), icterus and hepatosplenomegaly. Whilst the pregnancy and birth had not been affected by any particular problem, the mother, 18 days after giving birth, presented miliary and pleural tuberculosis. Despite treatment with rifampin, isoniazid and pyrazinamid started on day 22, the baby died on day 27 from multivisceral failure. The post-mortem liver biopsy confirmed the diagnosis of tuberculosis. Case 3. A baby born at term was hospitalized on day 4 for jaundice. Whilst the pregnancy and birth had not presented any problem, the mother developed a pleural tuberculosis on day 10. Breast-feeding was stopped. Due to the presence of opacities at the top of the right lung, the child was given rifampin, isioniazid, and pyrazinamide. The course was marked by the appearance of hepatomegaly and poor weight gain up to day 25, followed by an improvement.

CONCLUSION

The frequency of congenital tuberculosis is probably under-estimated. Its early diagnosis is essential but often difficult as the initial manifestations are delayed. Improved screening of women at risk and sensitization of the medical community are necessary.

[Congenital syphilis: update and perspectives]

Congenital syphilis is responsible for a variety of clinical symptoms, from subclinical attacks to septicemic forms that may be fatal. The most frequently encountered forms typically involve low birth weight, heptosplenomegaly and jaundice. Premature birth, anemia, cutaneous lesions, coryza, anasarca and pseudoparalysis may also occur. Neonatal X rays generally show characteristic but nonspecific osteochondrocyte lesions and periosteous dystrophy. A clinical form partly associated with growing tissues may be detected late. Diagnosis of fetal syphilis depends on the detection by immunofluorescence of specific IgM immunoglobulins in the newborn. Parenteral antibiotic treatment with 100,000 IU penicillin/kg.day for 15 days is given to newborns with symptoms. The classification and treatment of asymptomatic forms is unclear. A single injection of benzathine-penicillin is a good compromise between simple surveillance and admission to hospital for 10 days of intravenous treatment. In any case, serological surveillance is required to check that IgM disappears from the blood or that the titer of IgG decreases. Reinfection is always possible, even in a newborn treated correctly. In developing countries, pediatricians must be aware of the various clinical forms of congenital syphilis. In addition, national programs to combat sexually transmitted diseases should be supported and developed by international aid agencies. In economically advanced countries, attention is currently focused on the restricted nature of medical treatment. Improvements in the management of congenital syphilis depend above all on dealing with the social and cultural problems of populations affected by syphilis.

Placement of coronary stents in bifurcation lesions by the "culotte" technique

Coronary angioplasty of bifurcation lesions remains a technical challenge. Balloon angioplasty induces recoil and the "snow-plow" effect with a risk of side branch occlusion. The late result is associated with a high rate of reintervention. Randomized studies in nonbifurcated lesions have demonstrated better short- and midterm results after stent placement. We propose the "culotte" technique as a new technique to place intracoronary stents in bifurcation lesions: implantation of 2 similar stents in 2 steps in the main branch and in the side branch with overlapping of the 2 stents in the main branch before bifurcation. We performed this technique in 50 patients (in the left anterior diagonal branch in 33, in the left circumflex obtuse marginal branch in 12, in the right coronary artery in 4, and in the left main coronary artery in 1). The clinical success rate was 94% with 3 non-Q-wave myocardial infarctions. Late results indicated a 24% target lesion revascularization rate, which improved when a true kissing balloon inflation was used to achieve final deployment of both stents. This culotte technique is highly feasible and provides excellent short-term results. Assessment of its midterm benefit requires further study.

[Left ventricular kinetics studied by the color kinesis method. Comparison of bidimensional echographic and angiographic data]

The object of this study was to assess the value of CK in the evaluation of left ventricular wall motion. Fifteen coronary patients aged 56 +/- 12 years were included: 8 patients were examined after acute myocardial infarction and 7 after unstable angina with a history of myocardial information. The left ventricle was divided into 7 segments after a modified Heger model, excluding the basal septal and basal lateral segments not seen on angiography. The left ventricular wall motion was assessed in two-dimensional echocardiography (2DE) and colour kinesis (CK) by two observers and compared with the results of left ventriculography, considered the reference method. Over all the 105 segments studied (7 segments for each of the 15 patients), CK was significantly better than 2DE (80% of segments correctly evaluated by CK vs 68% by 2DE, p < 0.05). Colour kinesis significantly improved the study of all segments except the interventricular septum (67% vs 60%, p = NS). The inter-observer variability in 2DE and CK evaluated over 135 segments (9 per patient) by the kappa was improved by colour kinesis (0.57 in 2DE, 0.7 in CK). The authors conclude that CK enables evaluation of left ventricular wall motion with greater precision and less inter-observer variability.

[Myocardial infarction due to spontaneous coronary dissection during the postpartum period]

The authors report the case of a 34 year old woman, admitted to hospital because of myocardial infarction two months after delivery of her fifth child. The infarction was caused by spontaneous dissection of the left main coronary and left anterior descending arteries. Twenty-three months later, the patient was well with medical therapy. This case is an example of spontaneous post-partum coronary dissection which is the commonest cause of infarction occurring in that period. The physiopathology of this complication is not fully understood. The prognosis is poor, lethal in two thirds of cases. However, it must be emphasised that coronary dissection may regress spontaneously. Patients were previously referred systematically for surgery, but now it is usually reserved for cases with persistent myocardial ischaemia despite medical therapy. Angioplasty may be preferred despite the risks and may be successful in some cases.

[Myocardial infarction in a pregnant woman during salbutamol therapy]

The authors report the case of a 31 year old woman at 30 weeks' gestation who developed a non-Q wave postero-lateral myocardial infarction during treatment with salbutamol. There were no complications and delivery took place at term normally. Coronary angiography was performed 3 months post-partum and was normal: the Methergin test was negative. Myocardial ischaemia occurring during treatment with a beta-2 mimetic in pregnancy is rare and hardly ever progresses to myocardial infarction. The usual mechanism of ischaemia is an imbalance of myocardial oxygen demand and supply. Myocardial oxygen consumption is naturally increased during pregnancy and excess intracellular calcium secondary to the beta-1 stimulation occurring with the use of beta-2 mimetic drugs further aggravates matters. This hypothesis raises the question of the value of calcium inhibitors in these forms of myocardial ischaemia.

[Laparoscopic resection of ileo-cecal tuberculosis]

Rarely seen in industrialised countries, ileo-caecal tuberculosis does not require surgery unless complications or diagnosis uncertainly occur. When laparotomy is contre indicated in presence of chronical respiratory disease, laparo-assisted ileo-caecal resection is an interesting alternative to classical surgery as it has less effect on ventilation. This laparo-assisted ileo-caecal resection appears to the first reported in presence of intestinal tuberculosis.

Is dobutamine stress echocardiography useful for noninvasive differentiation of ischemic from idiopathic dilated cardiomyopathy?

Dobutamine stress echocardiography was performed in 56 consecutive patients, mean age: sixty-two +/- twelve years. Twenty-two patients had an idiopathic dilated cardiomyopathy (group 1) and 34 had angiographically proven ischemic dilated cardiomyopathy (group 2). Wall motion score index and left ventricular ejection fraction were determined at baseline, 5 micrograms/kg/min, peak, and ten minutes after stepwise dobutamine infusion. Worsening or no change in global wall motion score was observed in 9 group 2 patients (26%) and 1 group 1 patient (5%, P = .07). No significant difference was observed with regard to wall motion score index decrease between baseline and peak dose. Left ventricular ejection fraction increase during dobutamine infusion was comparable in both groups. Thus, an ischemic response was observed more often in the coronary artery disease group, yielding a good specificity and positive predictive value although sensitivity was low. However, left ventricular function improvement did not help to discriminate patients with or without significant CAD.

A T-DNA gene required for agropine biosynthesis by transformed plants is functionally and evolutionarily related to a Ti plasmid gene required for catabolism of agropine by Agrobacterium strains

The mechanisms that ensure that Ti plasmid T-DNA genes encoding proteins involved in the biosynthesis of opines in crown gall tumors are always matched by Ti plasmid genes conferring the ability to catabolize that set of opines on the inducing Agrobacterium strains are unknown. The pathway for the biosynthesis of the opine agropine is thought to require an enzyme, mannopine cyclase, coded for by the ags gene located in the T(R) region of octopine-type Ti plasmids. Extracts prepared from agropine-type tumors contained an activity that cyclized mannopine to agropine. Tumor cells containing a T region in which ags was mutated lacked this activity and did not contain agropine. Expression of ags from the lac promoter conferred mannopine-lactonizing activity on Escherichia coli. Agrobacterium tumefaciens strains harboring an octopine-type Ti plasmid exhibit a similar activity which is not coded for by ags. Analysis of the DNA sequence of the gene encoding this activity, called agcA, showed it to be about 60% identical to T-DNA ags genes. Relatedness decreased abruptly in the 5' and 3' untranslated regions of the genes. ags is preceded by a promoter that functions only in the plant. Expression analysis showed that agcA also is preceded by its own promoter, which is active in the bacterium. Translation of agcA yielded a protein of about 45 kDa, consistent with the size predicted from the DNA sequence. Antibodies raised against the agcA product cross-reacted with the anabolic enzyme. These results indicate that the agropine system arose by a duplication of a progenitor gene, one copy of which became associated with the T-DNA and the other copy of which remained associated with the bacterium.

[Value of fasciocutaneous tensor fasciae latae island flap in the treatment of large abdominal hernias. Apropos of a case]

One case of repeated incisional hernia is reported. This hernia was initially repaired but repeated infection occurred. This hernia was then successfully treated with a fasciocutaneous tensor fasciae latae island flap. The patient was reexamined two years after surgery and presented a functional abdominal wall. Other different reconstructive possibilities of regional myocutaneous flaps are described.

[Why so many stents?]

BETTER THAN ANGIOPLASTY: Prolonging inflation with a perfusion balloon decreases the risk of acute coronary occlusion after angioplasty. The longer the artery remains patent, the greater the chances of 0% residual stenosis. This is what the sent allows. Stent act on both mechanisms of stenosis: elastic recoil and fibrous remodeling of the arterial plaque. TARGETTED ACTION: Stents improve angioplasty prevention of acute stenosis. They have a real action on preventing degeneration of the saphenous graft and lead to a significant reduction in the rate of restenosis of the dilated site. There are however two specific complications: subacute occlusion and greater incidence of vascular events. Stents are particularly indicated for the treatment of restenosis and chronic occlusions. TWO IMPROVEMENTS: Risks related to the implantation of a foreign body in the vascular system have been reduced with the use of ticlopidine and high-pressure stent implantation. POSITIVE RESULTS: Stents have produced better angiographic results. They limit restenosis and the number of revascularizations required in treated patients. Several questions concerning indications remain open.

[Medical treatment after implantation of intracoronary stents]

RATIONALE FOR ANTITHROMBOSIS THERAPY: Introducing a foreign body into the coronaries raises the risk of thrombosis in the acute phase and for the 4 following weeks. The objective of antithrombotic therapy is to inhibit platelet adhesion and aggregation or to induce hypocoagulability. AT IMPLANTATION: High-dose heparin is given in a bolus following pretreatment with aspirin. ASPIRIN-TICLOPIDINE COMBINATION: The risk of subacute thrombosis is low, about 1%, and the rate of vascular complications is minimal. Treatment is simple and compatible with short hospitalization.

[Different types of coronary stents]

GENERAL CHARACTERISTICS: Several criteria are used for coronary stent design: biocompatibility, i.e. the capacity to resist thrombotic events and corrosion, flexibility, radial force sufficient to resist elastic recoil, percentage of the lesion covered, radio-opacity, minimal shortening at opening, absence of effect on collateral branches, possibility to use small calibre probe guides, and cost. TWO CATEGORIES: Both tubular stents (self-expanding stents and balloon stents) and filamentary stents (made of stainless steel or tantalum) are used, THE IDEAL STENT: There is no one ideal stent. Choice is dictated by the characteristics of the lesion and by the status of the artery to treat.

[Clinical, echocardiographic and Doppler outcome in ischemic right ventricular dysfunction associated with inferior wall infarction]

Right ventricular involvement during inferior wall myocardial infarction does not seem to alter long-term clinical prognosis but its specific outcome has not been clearly studied. We have previously demonstrated that pulmonary regurgitant (PR) flow tracings doppler analysis allows the accurate diagnosis of RV involvement, especially when the pressure half-time of PR was < or = 150 ms and the ratio of the minimal velocity to the maximal velocity was < or = 0.5. We studied 40 patients with acute inferior wall myocardial infarction and with PR flow. Doppler echocardiography was obtained during the first day, before discharge (early control) and between 12 and 24 months follow-up (late control). Among 22 patients with RV involvement defined with PR-derived doppler parameters (RVIPR). 8 had right ventricular enlargement and/or wall motion abnormalities, observed in 6 cases at early control and in 4 at late control. Doppler analysis showed remnant RVIPR parameters in 9 patients at early control and 8 among these at late contorl, with no relation with pulmonary artery pressure or other echocardiographic parameters. No clinical, angiographic or therapeutic data predicted these distinct echocardiographic and doppler patterns and the long-term prognosis was not different. At late control, among 12 RVIPR patients which PR-derived doppler parameters were normal at early control, two patients had still RVIPR pattern at late control and described ischemic recurrence. PR flow doppler analysis is a useful tool for diagnosis and outcome evaluation of RV involvement and shows a remnant diastolic dysfunction in half of the patients with acute RV involvement.

High prevalence of serological markers of cysticercosis among epileptic Malagasy children

Neurocysticercosis (i.e. cerebral localization of the metacestode larvae of Taenia solium) is believed to be a major cause of late onset epilepsy in non-Muslim developing countries. To define its role in childhood epilepsy in Madagascar, analysis of serological markers of cysticercosis was performed in 256 children with unexplained epilepsy and in 113 controls. Sera were considered positive when high titres in ELISA were present together with at least one of the bands 13, 14, 18, 21, 24 or 32 kD on Western blot. Altogether, 17.6% of the patients versus none of the controls were seropositive using these criteria. When analysing the bands of the Western blot, those of 13, 14 and 18 were significantly more frequently detected in sera of epileptic children than in sera of controls. Neurocysticercosis can be considered the main cause of secondary childhood epilepsy in our country, Madagascar being one of the most important foci in the world.

[Neurocysticercosis: pediatric aspects]

Neurocysticercosis is the most frequent parasitosis of the central nervous system in the world. Due to the extension of the pandemy, and the importance of the migrations from endemic countries, this parasitosis is being diagnosed with increasing frequency in France. Epilepsy is the main revealing symptom. However, in endemic countries, neurocysticercosis should be suspected in patients with any neurological sign. Diagnosis is based upon imaging procedures (computed tomography and magnetic resonance imaging) and serology (Elisa and Western blot). The evolution is highly variable, from complete latency to severe encephalopathy with psychomotor regression. Praziquantel and albendazole are the main therapeutic agents. Although corticosteroids are usually very effective on symptoms of the acute phase of the disease, their place in the treatment remains to be clarified. Racemic and ventricular forms of the disease usually need neurosurgery. In endemic regions, the diminution of the frequency of the disease relies upon prevention through health education compaigns, pending the achievement of an efficient vaccine.

[Isolated anomalous origin of a septal artery from a third coronary ostium. Apropos of a case]

The authors report the case of a patient undergoing coronary angiography for angina who had an anomalous origin of the septal perforator artery from a separate ostium. Anomalies of the coronary arteries may consist not only of anomalous trajectories and coronary fistulae but also of anomalous origins of the main coronary arteries. The anomalous origin of a septal artery from a separate ostium is very rare accounting for 0.5% of cases in the medical literature. In some cases, this artery provides a collateral circulation for occluded main coronary vessels, thereby preserving left ventricular contractility.

[Syncopal ventricular tachycardia complicating paroxysmal atrial fibrillation in severe myocardial ischemia]

The authors report two cases of spontaneous paroxysmal atrial fibrillation closely followed by syncopal ventricular tachycardia resulting in cardiac arrest requiring defibrillation. Both patients, men aged 62 and 64 years, had a past history of myocardial infarction without arrhythmias; atrial fibrillation occurred during severe myocardial ischaemia; coronary arteriography showed tight stenoses of the left main coronary artery with normal left ventricular function. Ventricular tachycardia (or fibrillation) during spontaneous paroxysmal atrial fibrillation is a rare occurrence. This sequence of events has been described in patients with accessory conduction pathways or in hypertrophic cardiomyopathy. It is an exceptionally rare complication of ischemic heart disease with only a very few previously reported cases. Myocardial ischaemia is probably the cause of the arrhythmia in together with irregularity of the ventricular contractions responsible for long cycle-short cycle sequences which are particularly arrhythmogenic and changes in sympathetic tone.

[Indications for percutaneous angioplasty and coronary surgery in stable angina pectoris]

Coronary by-pass surgery and percutaneous transluminal angioplasty (PTCA) have changed the prognosis and life quality of patients with stable angina. Medical treatment and myocardial revascularisation are both useful and most often complementary. Coronary by-pass surgery is indicated in the treatment of coronary left main disease and three-vessel disease with poor left ventricular function. PTCA is the best choice in patient with one-vessel disease resulting in myocardial ischaemia. Discussion remains open in other cases mainly in stenosis of proximal left anterior descending artery. Often the ultimate choice results from the limits of each technique: sapheneous by-pass occlusion or coronary artery restenosis after PTCA. New techniques and devices in revascularization are expected to improve prognosis:use of arterial by-pass grafts, gene transfer, local drug delivery.

Hemodynamic criteria for diagnosis of right ventricular ischemia associated with inferior wall left ventricular acute myocardial infarction

To test the diagnostic value of different hemodynamic indexes for the diagnosis of acute right ventricular (RV) ischemic dysfunction, we studied 2 groups of consecutive patients admitted for an acute left ventricular inferior wall myocardial infarction: 51 patients with (group 1) and 32 patients without (group 2) RV ischemia as determined by coronary angiography. In both groups, we analyzed by right-sided cardiac catheterization right-sided heart pressures, pulmonary capillary wedge pressure, and cardiac index. We also calculated pressure ratios (mean right atrial pressure or RV end-diastolic over pulmonary capillary wedge pressures), pulmonary vascular resistance, and RV stroke work index. We found significant differences (p < 0.01) between the 2 groups when comparing mean right atrial pressure, RV end-diastolic pressure, ratio of these 2 pressures over pulmonary capillary wedge pressure, RV stroke work index, and right atrial and RV pressure waveforms. The best combined sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were found for the right atrial M or W waveform pattern, isolated or combined with a disproportionate elevation of RV end-diastolic over pulmonary capillary wedge pressures (respectively, 92%, 94%, 90%, 87%, and 89%). Volume loading was performed in 27 patients (18 with and 9 without RV ischemia). Right heart pressures and RV stroke work index increased significantly and similarly in both groups. Cardiac index increased significantly only in patients without RV ischemia (p = 0.02). However, volume loading did not significantly modify the diagnostic value of the different hemodynamic criteria studied.(ABSTRACT TRUNCATED AT 250 WORDS)

Relations between Doppler tracings of pulmonary regurgitation and invasive hemodynamics in acute right ventricular infarction complicating inferior wall left ventricular infarction

To test the hypothesis that flow characteristics from pulmonary regurgitation (PR) can predict right ventricular (RV) involvement in patients with inferior wall acute myocardial infarction, we prospectively recorded continuous-wave Doppler tracings and right-sided cardiac hemodynamics in 48 consecutive patients with inferior wall acute myocardial infarction and PR. Right heart hemodynamics enabled the identification of 29 patients with (group 1) and 19 without (group 2) RV involvement. In patients with RV involvement, the pulmonary regurgitant flow pattern was characterized by a rapid rise in flow velocity to a peak level followed by an abrupt deceleration in mid-diastole, whereas in patients without RV involvement, the deceleration in mid-diastole was gradual. The pressure half-time of PR (PHTPR) and the lowest mid-diastolic to peak early diastolic velocity ratio were significantly lower in group 1 than in group 2 (91 +/- 31 vs 214 +/- 57 ms [p < 0.001], 0.35 +/- 0.08 vs 0.59 +/- 0.13 [p < 0.001], respectively). The best diagnostic accuracy (95%) was obtained with cut-off values of PHTPR < or = 150 ms and the lowest mid-diastolic to peak early diastolic velocity ratio < or = 0.5: sensitivity 100%, specificity 89%, positive predictive value 94%, and negative predictive value 100%. Using multiple logistic regression analysis, we found that PHTPR was the strongest predictor of RV involvement. Thus, these parameters, derived from pulmonary regurgitant tracings, are useful in the noninvasive bedside diagnosis of RV infarction.

Analysis of emergency department interpretation of electrocardiograms

The objective of the study was to determine the concordance of emergency physicians' and cardiologists' interpretations of emergency department (ED) electrocardiograms (ECG), to evaluate the impact of ECG misinterpretation on patient management, and to determine error rates as a function of the level of physician training and the specific ECG diagnoses. ECG interpretations were registered prospectively using a programmed-response data sheet. A second blinded interpretation by a staff cardiologist was assumed to be correct. Only ECG discrepancies with potential or probable clinical importance were considered as errors. The ED management of patients with ECG misinterpretations was reviewed by the investigators. The study was performed at an urban university hospital using 300 consecutive ED ECGs. The analysis found 154 errors of interpretation of which nine had probable clinical significance, and 56 had indeterminant significance. The concordance was weak at 0.69 (Kappa = 0.32, weighted Kappa = 0.30) with a significant discordance (McNemar Chi 2:P < 0.05). Error rates did not differ significantly between the diverse categories of physicians. In two cases, interpretation errors impacted patient management decisions but not patient outcomes. The most frequent errors involved repolarization abnormalities, ventricular hypertrophy and hemi-blocks. While discordance was significant, errors in ECG interpretation rarely impacted patient management. Prospective evaluation of ECG interpretation may be a useful means of gauging physician skills. It can also serve to focus educational activities on problem areas in electrocardiography.

[Treatment of bilateral inguinal hernia by subperitoneal prosthetic parietoplasty. Value of PTFE]

This retrospective study reviews 211 patients having sustained a bilateral groin hernia repair during a 3 year period. The procedure was the same for all the patients: via a Pfannensteil approach, a pre peritoneal prosthetic repair is performed, using two ePTFE patches, after resection of the hernial sacs and closure of the parietal gaps. The mean follow up was 2 years. During the post operative course, thirty seven of 211 patients sustained 10 local complications, 9 urethral catheter related complications and 11 residual pain. No prostheses infection or testicular atrophy was observed. Nine patients had recurrences (2.2% of 422 repairs). All the recurrences were due to incorrect technique, eight were successfully re operated on--Expanded PTFE is a reliable prosthetic material, easy to handle and well adapted to preperitioneal hernia repair.

"Pseudo-narrowing" during right coronary angioplasty: how to diagnose correctly without withdrawing the guidewire

The straightening of a sinuous proximal segment of a coronary artery using the stiffness of the guidewire has recently been recognized as likely to cause false coronary lesions. The accurate diagnosis between a true dissection and a pseudo-lesion is usually only done once all intra-coronary material has been removed into the guiding catheter. Such a manoeuvre may prove dangerous in case of dissection. We propose to demonstrate that it is possible to diagnose this phenomenon while leaving the guidewire within the coronary artery, and withdrawing it progressively until its floppy segment rests equally on either side of the suspect lesion.

[Early constrictive pericarditis after coronary revascularization. Apropos of a case]

The authors report a case of severe constrictive pericarditis occurring 6 weeks after coronary bypass surgery and in the absence of any other predisposing factor. The diagnosis was confirmed by CT scan and cardiac catheterisation which showed signs of a diastole. The patient died despite early surgical reoperation because of the severity of the pericardial fibrosis.

[Benign non-parasitic splenic cysts. 9 cases]

Benign non-parasitic splenic cysts are uncommon. Their diagnosis can benefit from ultrasounds and computed tomography. However, it may be difficult, before surgery, to distinguish between true cysts, which are congenital with epidermal lining, and false cysts, which are consecutive to a trauma, inflammatory or degenerative, without epidermal lining. We report nine cases of non-parasitic splenic cysts and try to determine the preoperative diagnostic approach. To prevent the overwhelming post-splenectomy infection syndrome, conservative surgical treatment is mandatory. Various surgical methods are discussed.

[Peritoneal puncture dialysis in the monitoring and treatment of hemoperitoneum of traumatic origin?]

The great diversity of injuries after abdominal wound, need an adapted treatment. When laparotomy is indicated in uncontrollable hemorrhage, peritoneal lavage associated with C.T. scan seems to be interesting in the management of hemoperitoneum with a moderate injury severity score and stable arterial and venous pressures. Three patients were recently managed non operatively with good results. The authors draw up these three cases with inclusion criterias and limits of the method.